Vsw Data Collection Form
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1DATA COLLECTION FORM
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(Employee to complete)
This is notice that your employer is participating in the Voluntary Shared Work Program (VSW). So that your employer
can file a complete application for unemployment benefits for you, you will need to complete this form with information
your employer may not have about your dependents, voluntary tax withholding preference, deductible pension, or county
of residence. You should only have to complete this form once unless you need to change something.
Name (Print full name)
Social Security Number
Please answer the following questions. If left blank, the default is "NO".
Voluntary Tax Withholding
If you choose to have income tax withheld from your unemployment benefits, you will need to complete and return the tax
withholding form that can be found in the "Facts About Unemployment Insurance" booklet that was or will be mailed to
you or view it on our Internet site at Tax withholding will start with your first payment even if the
form hasn't been returned.
Do you want to have 10% of your gross weekly unemployment payment withheld for Federal
income taxes?........................................................................................................................................
Yes
No
Do you want to have 5% of your gross weekly unemployment payment withheld for Iowa
income taxes?........................................................................................................................................
Yes
No
Dependents For Unemployment Purposes
To qualify as a dependent you must have claimed the person on your federal income tax return last year or be eligible to
claim them this year. To claim a spouse as a dependent, your spouse can only earn $120.00 or less in the week you
claim is filed. Children cannot be claimed by both spouses during the same year. You cannot claim yourself as a
dependent. You can only claim a maximum of 4 dependents.
Based on the information above, are you able to claim any dependents?............................................
Yes
No
Based on the information above, are you able to claim your spouse as a dependent?........................
Yes
No
Has your spouse filed a claim within the last 12 months?................................................................
Yes
No
If you plan to claim your spouse, did your spouse earn more than $120.00 last week....................
Yes
No
(Don't count self-employment)
Dependent Names
If you have qualifying dependents for unemployment purposes, please enter their names in the space below.
Qualifying Spouse's Name
Qualifying Child's Name
Qualifying Child's Name
Qualifying Child's Name
Qualifying Child's Name
Deductible Pension
Social Security benefits are not reportable on your unemployment insurance claim. Federal, Military or private employer
pensions need to be reported ONLY if you worked for the employer or served in the military during the past 18 months.
Are you receiving a pension that needs to be reported?.......................................................................
Yes
No
If you are receiving a reportable pension, select the type(s) of pension(s) you receive.
I receive a reportable pension from the Federal government where I last worked on:
Month/Day/Year
I receive a reportable pension from the Military and I last served in the Military on:
Month/Day/Year
I receive a reportable pension from a private employer and I last worked for this employer on:
Month/Day/Year
Citizenship
County of Residence
Yes
No
Are you a citizen of the United States?
(County Where You Live)
If no, enter your alien
authorization to work number
Signature
Date
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf, and hard of hearing, use Relay 711
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